Affecting millions of men (with around 150,000 new cases a year), prostate cancer once defied early diagnosis and almost always presented with late stage disease, often metastatic locally or at a distance, with a corresponding poor prognosis. Even today, about 26,000 men die each year in the U.S, from prostate cancer. Age-adjusted deaths from prostate cancer in 1986 were 34.9/100,000. That same year, PSA (Prostate Specific Antigen) was invented by Richard Albin as a lab test to detect early prostate cancer by means of a simple blood draw. When first introduced, it promised to revolutionize the detection and treatment of prostate cancer and presumably greatly reduce deaths from that disease. New diagnoses did increase from 119/100,000 in 1986 to a high of 180.3/100.00 in 2001, dropping to a low of 96.1/100,000 by 2014.
PSA allowed earlier detection of prostate cancer and initiated an era of earlier diagnosis and treatment, either surgical or radiological or some combination of the two. While drops in death rates have occurred (from 34.9/100,000 in 1986 to 19.1/100,000 in 2014) substantial prolongation of life remained elusive. While some morbidity associated with advanced prostate cancer also decreased, there was no significant increase in life expectancy, just fewer deaths from prostate cancer itself.
With subsequent research, it became clear that aggressive treatment did not benefit all men and that most would die of other causes than prostate cancer. The expression became that “you died with prostate cancer, but not from prostate cancer.” What’s more, the treatments carried significant possible side effects which included persistent urinary incontinence and impotence, not to mention considerable medical costs. Richard J. Albin, the inventor of the PSA test even said that use of his test was “a profit-driven public health disaster.”
It used to be recommended that all men be tested with a PSA at age 50 (or earlier with a family history of prostate cancer). The pendulum of recommendations from the USPTF (United States Preventive Task Force) swung back a couple of years ago, however, to a far more conservative stance. Doctors are now encouraged to do no systematic PSA testing except when the patient presents with signs of outlet obstruction (difficulty urinating related to prostatic hypertrophy) and then only after a one-on-one discussion about the risk and benefits of a diagnosis of prostate cancer. Biannual testing in African-Americans over 50 may be justified because of high rates of prostate cancer in that group. The same holds true for those with a significant family history of prostate cancer. PSA testing after 70 years of age is not recommended at all.
As mentioned, deaths from prostate cancer declined for decades after the advent of PSA (34.9/100,000 in 1986) to 19.1/100,000 in 2014). As in the pre-PSA past, however, late diagnosis has again became a reality, with associated significant morbidity and mortality. While most men with prostate cancer die “with the disease and not because of it,” those with advanced disease still die from prostate cancer albeit at a reduced rate from past decades.
So what should be done? Early testing (and better treatments) may have yielded a substantial reduction in deaths, but no prolongation of life. Doing nothing, however, does not seem justified. At the present, a talk with your doctor about urinary symptoms and a one-on-one discussion about risks and benefits of diagnosis and non-diagnosis of prostate cancer seems justified.
This ongoing debate, not unlike that associated with the use of mammograms, underlines the fact that all tests and all treatments must have a positive benefit to risk ratio. With additional data collection and analysis, we should be able to better define those who will benefit from the use of PSA versus those for whom its use will only add cost and inconvenience with no added years of life. In the end, the doctors must still follow the cardinal rule of medicine, “primum non nocere” (first, do no harm). And patients must make an informed decision based on facts and not emotions.
David J. Holcombe, MD, MSA
LOUISIANA PUBLIC HEALTH ASSOCIATION